A CECHE Publication on global health & environment issues Summer 2009 Vol. 4, Issue 1

DEVELOPED AND DEVELOPING NATIONS FACE OBESITY CHALLENGE Obesity and Overnutrition Trump Undernutrition in Newly Affluent Nations

Fatness was once a sign of power, prestige and beauty worldwide. Consider King Henry VIII, Fat Men’s Clubs and their well-to-do “fat cat” members, 200-pound “American beauty” and stage star Lillian Russell, and even the 13th century Mongol ruler and founder of the Yuan Dynasty Kublai Khan.

Is Obesity Contagious? Social networks may be the catalyst behind obesity’s rapid spread.

http://thesituationist.wordpress.com/2007/09/05/common-cause-combating-the-epidemics-of-obesity-and-evil/ Permission requested. While genes and environment provide the raw materials for weight gain, researchers report that friends, particularly close friends, may have the greatest influence on one’s weight. In fact, a person’s chances of becoming obese increase by 57 percent if he or she has a friend, near or far, who becomes obese – and the odds triple if that friend is mutually close, a seminal study reveals. Meanwhile, family members seem to have less impact, with obese siblings and spouses increasing the likelihood of obesity in their relatives by 40 and 37 percent, respectively.

Cont. on page 2

To be fat communicated prosperity and success, especially in cultures such as China and India that were historically prone to food shortages and famine. But until the past half-century, most Chinese and Indians were slim, either because they were engaged in physically demanding professions, or because they were impoverished and undernourished. The Epidemic Is Global The 21st century, however, is characterized by a global obesity epidemic. While about 850 million individuals around the globe battle undernutrition and almost 16,000 children die from hunger-related causes every day, more than 2 billion adults worldwide are overweight or obese,

Source: Obesity among US Adults, 2007, Centers for Disease Control and Prevention, Atlanta, GA

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according to the latest World Health Organization (WHO) data. A growing number of children – at least 20 million – are also confronting obesity, which may place them at risk of a shorter life expectancy than their parents.

Is Obesity Contagious? Cont. from page 1

Persons of the same sex have relatively greater influence on each other than those of the opposite sex, and the status of immediate neighbors did not affect the chance of weight gain in study participants. The same effect seems to occur for weight loss, but since most people were gaining, not losing, weight over the course of the study, the results are inconclusive for this variable. The study, published in July 2007 in the New England Journal of Medicine and referenced extensively since then, was based on a detailed analysis of a social network of more than 12,000 people. This population had been closely followed for 32 years, from 1971 until 2003 (via the federally funded Framingham Heart Study), and their relationships, as well as weight history, were well-documented over time and known to investigators. Study results indicate that obesity may be “a kind of social contagion” that spreads like a virus through networks of close contacts, note principal investigator Dr. Nicholas Christakis, a physician and professor of medical sociology at Harvard Medical School, and his colleague, James Fowler, an associate professor of political science at the University of California, San Diego. Christakis and Fowler suggest that this spread may have to do less with behavioral imitation and more with a change in social norms regarding the acceptability of obesity. In short, not only do friends influence what we eat and the activities and lifestyles we choose, they may also affect our perception of fatness. So when a close friend becomes obese, fatness in general and personal weight gain in particular may become more acceptable, and less actively avoided as a result. This unique analysis may shed light on how and why people have gotten so fat so fast in recent years. It also may help to short-circuit the effects of social networks on weight gain going forward – and enable us to incorporate the strong bonds of friendship to fight, rather than foster, fat.

In a study published in the July 2008 issue of Obesity, researchers at the Johns Hopkins Bloomberg School of Public Health conclude that unless eating or exercise habits change, 86 percent of the American population will be overweight or obese by 2030. Meanwhile, more than a third of American adults – over 72 million people – were already obese in 2005 and 2006, according to the Centers for Disease Control and Prevention (CDC). But America is not alone. “[A]ll of a sudden we're seeing the same problems in places where 20 years ago all they worried about was hunger: in Egypt, and among blacks in South Africa, and in China, where a third of adults now are overweight and obese,” points out Barry Popkin, professor of global nutrition at the University of North Carolina at Chapel Hill, in a December 2008 Newsweek Web interview. “In Mexico, nobody was overweight 15 years ago; now 71 percent of Mexican women and 66 percent of men are.” According to experts across the globe, the world’s obesity epidemic stems from a major shift in diet over the past century from primarily cereals to substantially animal products and fats, as well as an overall increased caloric intake, accompanied by a decline in physical work and activity precipitated by urbanization, and the rise and ubiquitousness of technology, motorized transportation and sedentary leisure activities, such as television viewing. In short, we are embracing less healthy food and more sedentary lifestyles. China Is A Prime Example Take China, for example. Plumpness was seen as a sign of prosperity, health and harmony with the spiritual world; it was celebrated, and sought, reports James L. Watson, Fairbank professor of Chinese Society and professor of

Anthropology at Harvard University, in “Prosperity versus Pathology: A social history of obesity in China.” Obesity remained at bay, however, until the late 1980s, when, Watson notes, “the dietary implications of rising affluence” weighed in and nutritionists like Georgia Gulden at the Chinese University of Hong Kong began to note unsettling trends: She recorded obesity rates exceeding 20 percent among certain subsets of male children in Beijing in 1995 and of 21 percent among Hong Kong 11-year-olds in the mid-1990s. From the cabbage subsistence days of socialism, in just two decades (beginning with Deng Xiaoping’s reforms in 1978), “China moved from a diet rich in grains and vegetables to one laden with red meat, sugar and edible oils,” Watson explains. Meanwhile, in Hong Kong, Shanghai and Taipei, the advent of convenience foods, take-out cuisine and food-on-demand has skyrocketed.

Source: Reuters file photo. Permission requested

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Popkin concurs. “Up until three years ago, there was no snacking in China,” he explains in his December 2008 interview. “Now it's exploding...Because all of a sudden, there are Chinese equivalents of Wal-Mart...[and] supermarkets everywhere, and everybody sees the same TV we see and wants the same things we want.” Meanwhile, “...people in the rural areas are as fat or fatter than they are in the urban areas,” due to the advent of “cheap food” and the replacement of physical labor with machines such as tractors, Popkin notes, citing both China and Mexico as examples. Interestingly, studies show that, while being a little chubby may slightly increase life expectancy, being overweight or obese is a definitive, and serious, health risk. According to data in a January 2009 Student BMJ article and the 2007 Textbook of Men's Health and Aging, approximately 80 percent of obese adults have at least one, and 40 percent have two, or more associated diseases such as diabetes, hypertension, cardiovascular disease, gallbladder disease and cancers. Developing Countries Set to Suffer Most The increase in obesity-related complications continues to be most noticeable in developing countries. In countries like China, at least 25 percent of the population currently is overweight or obese, and according to WHO statistics, hypertension increased 12 percent (or the equivalent of 160 million people) between 1991 and 2002. Meanwhile, WHO predicts that three-fourths of the more than 350 million

diabetics projected in 2025 will inhabit the third world, and that diabetes deaths will increase by more than 50 percent worldwide by 2016. According to the U.S. Department of Agriculture (USDA) September 2008 Amber Waves Internet Edition article “Obesity in the Midst of Unyielding Food Insecurity in Developing Countries,” already “an estimated 25-50 percent of the population in countries like Mexico, Thailand, and Tunisia suffer from diabetes,” and rates are surging in China. But it is India that has the largest number of diabetics, both diagnosed and undiagnosed. Data from the Diabetes Atlas, Third Edition reveal that, in 2007, India had 40.9 million diabetics age 20 to 79 – double America’s 19.2 million and more than any other country in the world. (China ranked second with 39.8 million.) Expected to reach a staggering 70 million by 2025, India’s diabetic population illustrates the projection that the developing world will bear the brunt of the rising obesity burden. Genetically vulnerable to diabetes and contracting it at an earlier age then people in developed countries, many middle-class Indians in particular confront both diabetes and obesity, and spend more than a quarter of their incomes to pay for diabetic treatments because of India’s dearth of medical insurance.

Source: Ji C, Sun J, Chen T. Dynamic analysis on the prevalence of obesity and overweight school-age children and adolescents in recent 15 years in China. Chin J Epidemiol 2004;25:103-8

Source: Barry M Popkin. Dynamics of the Global Nutrition Transition. Used with permission.

India is a prime example of the swift changes and stark dichotomy faced by many developing countries in the wake of the global tidal wave of obesity-promoting lifestyles, foodstuffs and behaviors. The country’s newly wealthy, urban middle class is adopting Western ways – and the resultant increase in body weight and noncommunicable

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disease burden associated with them – at the same time that the country is battling the malnutrition of millions in its impoverished rural regions. So, while around 45 percent of Indian children under five suffer from malnutrition, according to the World Bank, nearly half of India’s 250 million adolescents are overweight and 66 percent of women in New Delhi suffer from abdominal obesity, reveals a recent pan-India survey by the All-India Institute of Medical Sciences. In fact, the country that has more undernourished people than any other nation in the world also has one of the globe’s highest McDonald’s service volume averages, delivering fare to 13,000 customers per minute at outlets across India, reports Malaysia’s StarWeekend in a November 2008 article, “Rising obesity in India.” Source: UN, FAO and USDA-Economic Research Service (Food Security

Assessment, 2007) How and Why Do Obesity and Undernutrition Coexist? According to the September 2008 Amber Waves article, “The answer lies mainly in differences in income levels among and within countries,” and the resulting gross disparity in purchasing power, food choice, food consumption and lifestyle options. The “Food Security Assessment, 2007” conducted by the USDA’s Economic Research Service reveals that people in the lowest income quintile of a country tend to hold significantly less of that nation’s total income than those in the highest quintile. These poorer individuals eat accordingly, generally consuming less than the daily nutritional requirement, while those in the highest quintile exceed the requirement, sometimes by as much as 30 percent.

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Meanwhile, and especially marked in the higher income groups, “Average per capita food consumption in developing countries increased 28 percent between 1970 and 2005, three times the rate in developed countries.” At the same time, per capita income in developing countries nearly tripled during the period, the Amber Waves article notes, precipitating a shift toward increased calorie intake and the consumption of fattier and more processed foods,

particularly in money-infused, urbanized behemoths like China, Brazil and India. And although real food prices have increased over the past five years, they declined from 1970 until 2004, report Stacey Rosen and Shahla Shapouri in Amber Waves. This may explain why, between 1970 and 2005, per capita consumption of “...meat, eggs, and vegetable oils increased roughly threefold, while sugar increased 66 percent.” Developing countries with the highest number of urban dwellers tend to maintain higher-calorie diets – and higher obesity rates. According to Chinese Academy of Medical Sciences’ Dr. Yangfeng Wu in a 2006 BMJ editorial entitled “Overweight and obesity in China,” data from China

national surveys of nutrition show that “[e]nergy intake from animal sources has increased from 8% in 1982 to 25% in 2002, and the average energy intake from dietary fat among urban Chinese increased from 25% to 35%,” exceeding the maximum 30 percent recommended by WHO. Meanwhile, in India, two of every three urban women over the age of 35 are overweight or obese, according to the newly released results of a three-year national multi-site study on nutrition and nutrition-related noncommunicable diseases funded by the country’s Department of Science and Technology. Urban consumers are presumably the driving force behind the more than fivefold growth between 1970 and 2005 in imports to developing countries of highly processed foods such as canned meats, breakfast cereals, pastries and wine. The surge in supermarkets – which in the last 20 years have become almost as ubiquitous in the developing world as in the developed – has fueled

the prevalence of such convenient, and culpable, consumables as well.

Source: UN, FAO and USDA-Economic Research Service (Food Security Assessment, 2007)

And, of course, there is culture. “The likelihood of being overweight in the poorest 25% of the population is twice that of people in the highest quarter of economic class,” states Dr. Kelly D. Brownell, co-founder and director of Yale University’s Rudd Center for Food Policy and Obesity, in a 2007 LA Times series entitled “The Great Fat Debate.” Thus, while overweight and obesity are associated with

poverty and lower income groups in developed Western countries today, in developing countries such as China and India, obesity may be rooted in the age-old cultural belief that “excess body fat represents health and prosperity,” explains Wu. Bigger children are often considered evidence of affluence and success in China, for example, and with the country’s one-child rule, overweight youth are a dime a dozen, as food that used to be shared by multiple siblings prior to 1979 is now consumed by one person, observes George Washington University’s Dr. Tsung O. Cheng in a July 2008 reader’s letter on Beijing Review.com. How to Halt the Epidemic Just a few years ago, China was already spending about 5 percent of its gross national product (GNP) on direct and indirect costs related to poor diet, lack of physical activity and obesity, according to Popkin in the August 2006 National Geographic News article “Obesity Explosion May Weigh on China's Future.” As overweight and obesity figures there continue to skyrocket, “...it’s only a matter of time before obesity-related spending catches up to that of the United States, which spends 17 to 20 percent of its GNP on related costs,” Popkin says. Echoing this sentiment, Student BMJ “Obesity in the developing world” authors Hannily Harvey and Janneke Patterson contend that “[i]nevitably, a reallocation in government healthcare spending will be required if any progress is to be made in halting the progression of this phenomenon. Unfortunately, in countries where economic and social resources are minimal, diverting monetary focus could lead to abandonment of the ongoing campaign against infectious disease.” But lifestyle changes could have a major, positive impact. In its “Facts Related to Chronic Diseases,” WHO states that up to 80 percent of cases of coronary heart disease, 90 percent of cases of type 2 diabetes and one-third of cancers could be avoided by switching to a healthier diet, increasing exercise and stopping smoking. (See www.who.int/dietphysicalactivity/publications/facts/chronic/en/print.html.) For example, a Mediterranean diet, which is rich in vegetables and fiber with moderate amounts of red meat and fat, and a high proportion of monounsaturated fat (mostly from olive oil and nuts), provides cardiovascular benefits, according to articles in a 2006 Annals of Internal Medicine and a 2008 New England Journal of Medicine (NEJM). Other studies indicate that such a diet may be beneficial for weight loss. In addition, a two-year “Dietary Intervention Randomized Controlled Trial” published in a July 2008 NEJM found that a low-fat, restricted-calorie diet, a Mediterranean, restricted-calorie diet, and a low-carbohydrate, non–restricted-calorie diet led to mean weight loss (of 3.3 kg, 4.6 kg and 5.5 kg, respectively) and precipitated significant reductions in insulin levels in participants both with and without diabetes. While improving diet is essential, it is not always considered – and quite often ignored. In India, for instance, the

middle- and upper-income individuals who represent the bulk of the country’s obese population and who can afford to buy fruits and vegetables aren’t. They instead spend their rupees on fried, sugary, salty, obesity-generating snack foods, which are no less expensive than healthy foods, and in fact, often cost more. Such behavior belies deeply rooted cultural norms, as well as a certain backwardness associated with a lack of awareness and education. This is where government agencies, nongovernmental organizations, industry and educators can play an important role. Programs and Partnerships According to “Obesity...At A Glance 2009,” a publication of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, “[p]ublic health approaches that affect large numbers of different populations in multiple settings...are needed. Policy and environmental change initiatives that make healthy choices in nutrition and physical activity available, affordable, and easy will likely prove most effective in combating obesity.” And this is true across the globe. The CDC itself actively develops partnerships and sponsors state-based programs, as well as national ones, like the YMCA’s extensive “Activate America: Pioneering Healthier Communities™” project, which promotes the development of effective strategies and programs for healthy living in communities across the United States. The CDC also convenes national leadership activities and is leading development of the “National Roadmap for Obesity Prevention and Control,” expected to be unveiled in 2010. On the international front, WHO and its “Global Strategy on Diet, Physical Activity and Health” form the backbone of many a program and policy, including Britain’s multimillion-dollar “Change4Life” anti-obesity campaign, which employs media outlets, the Internet and a helpline to educate and curtail the consequences of poor diet and inactivity, and is the country’s biggest obesity-related marketing campaign to date.

Source: http://www.nhs.uk/change4life. Used with permission.

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There are also major campaigns underway in many parts of the world to promote vegetables and fruit, or a plant-based diet. One such vigorous program is the “5-A-Day The Color Way” campaign that started in the United States in the 1990s

and recently debuted in Europe. “5-A-Day” is a coalition of the U.S. National Cancer Institute, the Public Benefit Foundation, the fresh produce and agriculture industries, Wal-Mart and a host of others, including educators and media. It promotes consumption of at least five servings of vegetables and fruits each day using clever and persuasive ads, public service announcements and promotional materials for adults and children, and it has had a small, though measurable, impact in increasing vegetable and fruit consumption in the United States. But it is in developing countries where such public health approaches are needed most – and fortunately, some are beginning to take root. The CECHE-supported and Center for Science in the Public Interest-led “Global Dump Soda Campaign,” for example, aims to prevent obesity in children by curbing soft drink consumption, and inappropriate and aggressive marketing in less developed countries. The Indian version of the program, which involves a partnership with the consumer advocacy coalition VOICE, is even broader in scope, targeting not just soda, but all fatty, fried, and high-salt and -sugar foods. Singapore’s Holistic Health Framework (HHF) specifically addresses schoolchildren, focusing on improving physical fitness and mental and social well-being through healthy lifestyle choices. The HHF replaces the country’s 15-year ministry-managed “Trim and Fit” program, which was, according to the September 2008 Amber Waves article, “...credited as one of the most successful programs in the world in terms of sustained obesity management.” Consisting of “teacher and student education, changes in school lunches, assessment of students, and increased physical activities during school time...,” the program, which was disbanded after being criticized for “targeting overweight children and thereby stigmatizing them,” saw the percentage of students who passed the government’s national fitness test increase from less than 60 percent in 1992 to more than 80 percent in 2002, and the portion of overweight students drop from 14 percent in 1992 to 9.5 percent in 2005. Also aiming to control obesity among schoolchildren is China’s national Health Promoting Schools project. A collaboration with WHO, the project includes more than 50 schools in 11 cities across the country’s Zhejiang Province. The schools implement interventions through a host of actions, including establishing health-related policies, improving physical environments and promoting a sense of

individual responsibility for health-related behaviors and lifestyles. Based on an earlier pilot program, results have been inconsistent, with limited studies indicating everything from significant benefits in the intervention group for girls and boys after one year, effectiveness in girls only after 10 months, and the inability to effectively prevent and treat obesity after two years. Several other obesity-related intervention programs have also been implemented in China since the 1990s with varying results. For example, Jiang, Xia, Greiner, et al conducted a two-year family-based behavior treatment program in early 2000 among 68 obese children in a Beijing middle school whose published results showed a 2.9 (or 9.8 percent) decrease in BMI and a 2.5 kg m-2 reduction, as well as a 5.5 percent dip in total cholesterol and a 9.7 percent drop in triglycerides in the treatment group. Meanwhile, two-year individualized interventions among adults, including a 2006 study on “the effect of community-based integrative intervention on hypertension in Guangzhou” and a 2001 “dietary intervention study on the hypertensive high risk population in a northern rural area of Beijing,” saw 6.8 percent of the overweight/obese subjects in the intervention group of the first program lose weight to reach a normal BMI; and the overweight rate decrease 3.5 percent in the intervention group, while rising 18 percent in the control group in the latter, rural initiative.

Source: Public Benefit Foundation Used with permission.

Action Required By all accounts, the world has become “obesogenic.” As the above examples show, some efforts are underway to beat this global trend towards weight gain driven by the overconsumption of unwholesome foods combined with a sedentary lifestyle. However, it is apparent that, to succeed, there needs to be a massive and sustained global multi-faceted effort comprising national and local components that especially target children in schools and at home, because that is when and where food habits are formed. Among the key components of this effort should be extensive, sustained mass media initiatives to educate the public about obesity and how to prevent it. But while the “5-A-Day” and “Change4Life” campaigns are making headway in developed countries, public education programs that target obesity in developing nations like India and China have yet to take advantage of a growing opportunity to reach the public through television and other mass media to inform and motivate them to change their lifestyles. Also fundamental to combating obesity is controlling junk-food advertising and availability, and requiring regular physical activities at schools, á la the United Arab Emirates, where the Ministry of Education plans to ban junk food in all public and private schools across the country and will ensure that each student exercises daily for at least 30 minutes through intensive one-on-one training.

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Updating decades-old school nutrition standards would also pack a punch. And currently in the United States, legislation has been proposed in the House of Representatives and the Senate to update nutrition standards for the foods sold alongside school meals in the cafeteria, as well as in vending machines and school stores, and to broaden the 1979-era standards to apply everywhere on campus during the whole school day (as opposed to only in the cafeteria during mealtimes).

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Farm subsidies programs could also be restructured to favor nutrient-dense rather than calorie-packed produce. And countries, states or provinces could tax sugary and high-calorie beverages, as proposed by New York Gov. David Paterson in his January 2009 “State of the State” address, during which he asserted that an 18 percent tax on soda and other soft drinks would reduce consumption by 5 percent and raise $404 million next year to fund obesity prevention and other programs in the state. Brownell and Dr. Thomas R. Frieden also make a public policy case for taxes on sugared beverages. In their April 30, 2009 NEJM article, they present data that indicate that higher prices reduce soda consumption and that a tax on sugared beverages – even a

one-penny-per-ounce excise tax – could cut consumption by more than 10 percent and encourage consumers to switch to more healthful beverages. Legislating basic medical coverage in countries like India, where insurance is insubstantial at best, could also have profound effects. So could “mandat[ing] insurance coverage for preventing and treating pediatric obesity,” argues Dr. David S. Ludwig of Harvard Medical School and the Optimal Weight for Life Program at Children’s Hospital Boston. No single approach is sufficient to win the fight against overweight and obesity, but beginning with even one of these initiatives would give the challenge a renewed sense of urgency and, most importantly, a chance. It is in developing countries that we have a historic opportunity to halt, or at least minimize, the epidemic of obesity. And experience in industrialized countries tells us that this can and must be done.

________________________________________Secondary Lead

THE ECONOMICS OF OBESITY: Excessive Weight Gain Taxes Individuals, Nations, Environment Obesity exacts a heavy toll worldwide. And payment is not just in the form of poor personal health and a series of debilitating and potentially fatal health problems, such as hypertension, type 2 diabetes, heart disease and stroke. Being obese has significant financial implications, from lower and lost income to added personal, public and even environmental costs. Lower Income According to Stanford University researchers, obese U.S. men and women earn, on average, $3.41 per hour less than their peers. This translates into $7,093 in lost annual income per obese person. In 2005, the National Bureau of Economic Research revealed that the income gap increases as these employees age, and that obese workers are paid less when they have employer-sponsored health insurance, because, research shows, they pay in the same premiums as thinner employees, but have higher medical expenses (between 29 and 117 percent higher, according to the Centers for Disease Control). Obese white women may suffer most, at least in the United States, where, reports John H. Cawley of Cornell University, a weight of 64 pounds above the average for white women was associated with 9 percent lower wages.

Source: Jay Bhattacharya, “PUBLIC HEALTH: Dollars to Doughnuts,” Hoover Digest 2007:3 (published by the Hoover Institution, Stanford University). Used with permission.

Overweight and obesity are also linked to poor academic performance, according to researchers at University of

Minnesota’s School of Public Health. In addition, heavy people tend to accumulate less overall wealth: A 2004 study by Dr. Jay Zagorsky of The Ohio State University compared net worth with BMI (body mass index) scores and found obese Americans to be approximately half as wealthy as thin ones.

Lost Productivity, Lost Income Obese workers also lose an average of a week of work a year because of weight-related ailments, reports the National Institute of Diabetes and Digestive and Kidney Diseases. In fact, a company of 1,000 employees loses $285,000 annually due to obese workers, and 30 percent of that (or $85,500) is because of increased absenteeism, note Eric A. Finkelstein and Laurie Zuckerman in their 2008 book, The Fattening of America. Meanwhile, in Australia, for example, an estimated $1.7 billion is lost annually from a drop in output caused by reduced employment and premature death of obese individuals, according to a 2006 Access Economics analysis commissioned by Diabetes Australia. Such statistics cause Student BMJ authors Hannily Harvey and Janneke Patterson to muse that “A nation’s developmental gains could...be undone by a large reduction in the people’s capacity to work.” Higher Personal Costs Excessive weight also taxes personal gains. Overweight U.S. males, for example, pay $170 more in medical costs annually than their leaner co-workers, while the costs for overweight U.S. females are $495 higher, point out Finkelstein and Zuckerman. In 2002, spending on medical care related to obesity accounted for 11.6 percent of all private health care spending, compared with 2 percent in 1987, and the numbers keep rising. In fact, between 1987 and 2002 alone, the share of private health spending attributable to obesity soared more than tenfold, from $3.6 billion to $36.5 billion, according to a study published online in the journal Health Affairs. In addition heavy people pay two to four times more for life insurance premiums than “normal-size” individuals.

Even travel costs more. In mid-April, for example, United Airlines began requiring people needing a second seat because of their size to pay more for the extra seat; and

starting in 2002, budget airline Southwest began enforcing its 22-year-old policy requiring overweight or obese passengers who need all or part of two seats to purchase two tickets. Clothing expenses are also higher, as tall and plus size products tend to cost more than average sizes to cover the expense of the extra materials. Meanwhile, in developing countries like India, obesity-related conditions such as diabetes are depleting the assets of, and in some cases even bankrupting, scores of middle-class urbanites, who may spend more than a quarter of their incomes on diabetic treatments because of a nationwide lack of medical insurance. Higher Public Costs And then there are the increased costs to society. In the United States: These increased costs amount to a whopping $93 billion annually, says Finkelstein. According to Dr. Kelly D. Brownell and Dr. Thomas R. Frieden in an April 2009 issue of the New England Journal of Medicine (NEJM), an estimated $79 billion is spent every year just on health care related to overweight and obesity, “and approximately half of these costs are paid by Medicare and Medicaid, at taxpayers’ expense.” A 2004 Economics of Obesity report by Jay Bhattacharya of Stanford University and Neeraj Sood of the RAND Corporation details that “the lifetime medical costs related to diabetes, heart disease, high cholesterol, hypertension, and stroke among the obese are $10,000 higher than among the non-obese.” Meanwhile, as reported in a December 2006 article in the monthly insurance magazine Best’s Review, “Kaiser Permanente studies show that a weight gain of 20

pounds results in more than $500 per person of increased costs over the next three years...So anytime someone gains some weight, there's cost to the health-care system." In California, the cumulative costs of physical inactivity, obesity and overweight among the state's workers was $21.7 billion in 2000, with physical inactivity totaling $13.3 billion, obesity $6.4 billion, and overweight $2 billion, according to a 2005 report. The report found that about three-quarters of the costs – more than $16 billion – were assumed by public and private employers in the form of health insurance and lost work productivity. (It also contended that if one or two of every 20 overweight and/or sedentary Californians became leaner and more physically active, the state could save about $1.3 billion per year.)

Source: “The Economics of Obesity: Is Public Policy Justified”, American Journal of Managed Care, Vol. 4:3 141-145. 1998. On the opposite coast, New York spends $6.1 billion each

year to treat obesity-related health problems, according to recent statistics released by the state governor’s office. In addition to the increasing financial burden on national and state health care coffers, hospitals have to pay more to

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treat the obese. Oversized wheelchairs can cost about $2,500, eight times the cost of an ordinary wheelchair, explain Finkelstein and Zuckerman in The Fattening of America, and operating tables that are strong enough to support the severely obese can run as much as $30,000. Around the Globe: Obesity could cost the global economy as much as malnutrition, warns the World Bank. In 2001, Barry Popkin and his colleagues at The Food Policy Research Institute reported that China sacrificed more than 2 percent of its gross domestic product to cover the costs of diet-related chronic diseases – more than it spent on undernutrition. By August 2006, Popkin noted in National Geographic News that the cost to China of poor diet, physical inactivity and obesity was now up to 5 percent of the country’s gross national product (GNP), and that it was only “a matter of time” before obesity-related spending there caught up to that of the United States, “which spends 17 to 20 percent of its GNP” on such costs. According to a November 2006 Natural News article, 6 percent of health costs in the World Health Organization's European region are a result of obesity in adults. For example, obesity cost France $6.41 billion in direct outlays in 2002, and in July 2008 following publication of Britain’s largest obesity study, the country’s health secretary estimated that obesity-related costs to Britain’s National Health Service were likely to rise sevenfold by 2050. Meanwhile, including indirect costs, the price tag for obesity in Australia was an estimated $21 billion and $58 billion in 2005 and 2007, respectively, based on studies commissioned by Diabetes Australia. One special concern is that obesity-related costs could overwhelm the health care systems of developing countries. This may especially apply to China and India, which are already reeling from outlays associated with communicable diseases and malnutrition, and where, according to the World Bank, average per capita health expenditures “are less than 10 percent of expenditures in developed countries,” explain Stacey Rosen and Shahla Shapouri in their September Amber Waves article, “Obesity in the Midst of Unyielding Food Insecurity in Developing Countries.” Environment Costs In addition to personal and public pocketbooks, obesity taxes the environment. Heavier passengers burn more fuel, for example. According to a 2004 Centers for Disease

Control report, Americans' average weight increased by 10 pounds in the 1990s, causing airlines to spend $275 million on an additional 350 million gallons of fuel to support that extra weight. And a 2006 study published in The Engineering Economist found that Americans pumped 938 million more gallons of fuel a year than they did in 1960 because of their “heftier frames.” This increased annual gas expenditures nationwide by $3.55 billion (and added to environmental pollution). Double Jeopardy Becoming obese may itself be a question of economics, at least for certain segments of society. In their January 2006 commentary in Nature Medicine, Derek Yach, David Stuckler and Brownell cite five factors that have “tipped the

balance between caloric intake and expense to an unfavorable equilibrium.” They are:

Source: Kelly D. Brownell and Thomas R. Frieden, "Ounces of Prevention — The Public Policy Case for Taxes on Sugared Beverages," NEJM, April 9, 2009. Used with permission from Dr. Kelly Brownell.

• expanding labor market opportunities for women • increased consumption of food away from home • decreased requirements of occupational and

environmental physical activity • rising costs of healthy foods relative to unhealthy

ones • growing quantity of caloric intake with declining

overall food prices. The “economics of food choice” figure particularly prominently in the obesity equation, contend Adam Drewnowski and Nicole Darmon in a 2005 article in The American Journal of Clinical Nutrition. In short, people use price as a guide to food shopping. In simple terms, sweets and fats cost less, whereas vegetables and fruits cost more, so more and more people are opting for less expensive energy-dense simple carbohydrates over healthier legumes – and putting themselves at risk for obesity. That’s not to say that unhealthy food is cheap. Snacks, soda, desserts and prepackaged ready-to-cook foods are not only calorie-dense and laden with sugar, fats, and salt, but many

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prepackaged meals are also much more expensive than freshly prepared ones. It is a cost associated with convenience, as freshly prepared food entails more physical activity and energy expenditure than oven-ready dishes. Nevertheless, studies conducted in Australia, Canada and the European Union have found that healthier diets cost more, and studies of increases of the number of obese adults in the United States (Lakdawalla and Philipson 2002; Chou, Grossman, and Saffer 2004) reveal that much of America’s obesity trend can be attributed to lower prices, reports the September 2008 issue of Today’s Research on Aging. The same publication points to research that shows that the drop in food prices between 1980 and 2005 may have accounted for up to 40 percent of the increase in BMI since 1980. “[T]he changing incentives that people face have conditioned unhealthy choices to become the economically smarter choices,” note Yach, Stuckler and Brownell. Finkelstein agrees. “Modern society is giving Americans many more incentives to gain weight than to lose it,” he quips in a February 2008 interview, citing new technologies and the “abundance of cheap, tasty foods” as “the two most obvious factors.” Meanwhile, he notes, the health costs of obesity are actually declining: “...research by the Centers for Disease Control reveals that today’s obese population has better blood pressure and cholesterol values than normal-weight adults did 30 years ago..[and] if the costs of being obese go down, and there are people who like to eat and don’t like to exercise, we are bound to see obesity rates go up.” Which, apparently, is what has happened. Fat-cutting Measures Past efforts suggest that “information-based strategies...will have a limited impact” in tackling the problem of obesity, contend Finkelstein, Christopher Ruhm and Katherine Kosa in “Economic Causes and Consequences of Obesity.” And most experts agree. Success on the obesity front will require multifaceted interventions – and fiscally driven ones. According to Yach, Stuckler and Brownell, “market-led solutions, along with public policies, may combine to make healthy choices the economically easy and readily available choices.” They discuss the development of country-specific roadmaps to determine which approaches would have the greatest national impact. In The Fattening of America, Finkelstein and Zuckerman argue that in the United States “the government should revisit past policies that may have inadvertently helped promote the rise in obesity rates.” They point to agricultural subsidies for farmers, zoning laws that discourage pedestrian transportation, subsidies to employers for providing health insurance, and even the existence of the Medicare program. And then there are the 30-year-old national nutrition standards in effect in the vast majority of U.S. public schools. These standards prohibit the sale of seltzer water, but include pizza, doughnuts and cheeseburgers, as well as

vending machines hawking soda and junk food, on school menus and in school buildings. Past policies should certainly be reevaluated, but new measures need to be instituted to reduce the costs – physical, social and economic – of obesity worldwide. Proposed market and policy options around the globe include higher taxes on unhealthy foods and beverages; the regulation of fast foods and food advertising; and the mandatory inclusion of calories on restaurant menus on more than a local level. Taxing Unhealthy Eating Studies show that cost matters. So targeting people’s pocketbooks may be a sound first step both to curbing the consumption of unhealthy items and to generating funds to implement additional obesity-battling measures. Such an approach would feature price changes and taxes, as well as financial incentives. It may also benefit people who can most afford choice, unless in the process of making unhealthy foods financially unappealing, the prices of healthier items are reduced or subsidized to allow those segments of the population most affected by the relationship between price and obesity to afford to make healthy choices. Everybody must eat, but the cost of basic food products needs to remain in line with the average person’s paycheck. In a 1999 study conducted in China and published in The Journal of Nutrition,” Xuguang Guo, Barry Popkin, Thomas A. Mroz and Fengying Zhai found that an increase in the price of an individual food group led to significant reductions in the probability of consuming any food within that food group – and on the quantity of food consumed. For instance, price changes for animal protein foods had a large effect on reducing fat intake, a primary contributor to obesity in China. Since people, especially those facing economic constraints, tend to forego more expensive foods for less expensive ones, increasing the cost of foodstuffs that play a pivital role in the development of obesity, such as animal proteins, fats and sugars, while simultaneously demonizing them in a cultural context, could limit their consumption. A price-policy approach would be both technically and politically complex to execute, but it is, nonetheless, a viable option – one that must take into account cultural and socio-economic tendencies. In Scandinavia, for example, aggressive state policies related to taxation and import tariffs are believed to have had an effect on dietary choices and public health (Milio 1990 and 1991). And Yach, Stuckler and Brownell remind us that high taxes on cigarettes have proven to be one of the most effective ways of reducing smoking rates. “Data indicate that higher prices also reduce soda consumption,” note Brownell and Frieden; they cite a review by Yale University’s Rudd Center for Food Policy and Obesity suggesting that for every 10 percent increase in price, consumption decreases by 7.8 percent, as well as an industry trade publication report revealing that as prices of carbonated soft drinks increased by 6.8 percent, sales dropped by 7.8 percent. Taxes and tariffs in particular can also generate substantial revenue while conferring health benefits – especially when

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applied to heavily consumed items. According to Brownell and Frieden in their 2008 NEJM “Ounces of Prevention — The Public Policy Case for Taxes on Sugared Beverages,” something as seemingly insignificant as a penny-per-ounce excise tax on such drinks would raise an estimated $1.2 billion in New York State alone. This money could fund anti-obesity efforts, including healthy food programs, but, they emphasize, “only heftier taxes will significantly reduce consumption.” Nonetheless, even this penny-per-ounce excise tax could reduce consumption of sugared beverages by more than 10 percent – results an education campaign would be hard-pressed to deliver.

Source: http://allday.msnbc.msn.com/archive/2007/08/10/312031.aspx. Company Fires Workers for being Overweight. Posted: August 10, 2007 by Noah Oppenheim

The Means to Motivate Insurance premiums tied to weight could also encourage healthier living. Bhattacharya and Sood, for example, found that health insurance that allows underwriting on weight, and in which premiums are a function of weight, may help to curb obesity because consumers are given financial incentives to shed pounds in the form of lower premiums. “Because consumers face the full costs of their weight choice through the health insurance premium, they choose to lose weight even when fully insured,” they explain, noting that this does not happen with full insurance, when underwriting on weight is not allowed.

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Employers too could play a key role in supporting healthy lifestyles and reducing obesity by “promoting wellness in their workforce.” In fact, companies that bankroll workplace health promotion programs reap average “savings of $3 for every $1 invested,” report Yach, Stuckler and Brownell. That may be one reason why, according to Dr. Susan Okie in her 2007 NEJM article, “The Employer as Health Coach,” many of today’s larger companies, like General Mills, are tackling employees’ bulging waistlines and burgeoning medical bills through annual health risk assessments and a host of health-related offerings such as free preventive services at work, subsidized corporate cafeterias that serve nutritious, low-calorie choices, and even on-site medical clinics, gyms and pharmacies. To encourage workers with chronic diseases to take medication, for example, Pitney Bowes reduced co-payments on all drugs for hypertension, asthma and diabetes to 10 percent; and while the company's spending on these drugs increased, its overall costs for the three diseases dropped and its health

costs per employee were reported to be roughly 20 percent below those of comparable employers. The Bottom Line The economic rationale for public policy action in the case of obesity is clear. So why isn’t more being done? According to Yach, Stuckler and Brownell, the areas of food, nutrition and physical activity are far-reaching and complex. They comprise numerous vested, and monied, interests, including governments, politicians, health care systems, insurance giants, multibillion-dollar food companies, the fitness industry, and billions of independent-minded consumers. The stakes are high, and real progress will require broader alliances and stronger bonds between public, private and civil societies. Forging those bonds is imperative if effective intervention is to take place and the cumulative costs of obesity are to be controlled, capped and curtailed. Otherwise, “the costs of obesity might well become catastrophic,” laments Dr. David Ludwig of Harvard Medical School in the NEJM. And the sacrifice of human life and productivity would be immeasurable.

________________________ __________CECHE NEWS

CECHE Promotes Healthy Hearts CECHE is dedicated to improving health across the globe. Among its major projects are two that especially pertain to obesity. The Global Dump Soft Drinks Campaign tackles a subset of what may be the single largest driver of the obesity epidemic: the consumption of sugared beverages. (See In Focus, Vol. 3, Issue 2, http://www.ceche.org/publications/infocus/summer2008/ne

ws.html). The initiative aims to reduce intake of sweetened, high-calorie carbonated beverages to improve diet and health worldwide through information dissemination, industry partnerships and media coverage. In addition, CECHE is collaborating with the Center for Science in the Public Interest (CSPI) to support the Campaign for Healthy Hearts, a program designed to promote public health policies to reduce cardiovascular

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disease (CVD), for which obesity is a major risk factor. CVD is the leading cause of death in the United States, with coronary heart disease and stroke killing some 650,000 each year, and medical procedures, statins and other medications for these illnesses costing Americans $90 billion annually. Since 2004, CSPI has been working with CECHE support to develop advocacy strategies to fight CVD. In addition to partnering with experts and encouraging a more plant-based diet, the Campaign for Healthy Hearts champions the need to eliminate trans fat and reduce the amount of sodium in diets. Most recently, strides have been made on the sodium-reduction front. In July 2008, CSPI, in conjunction with the Association of State and Territorial Health Officials and the National Association of County and City Health Officials, hired salt and hypertension expert Dr. Steven Havas to coordinate a unique private meeting of state and local health department officials from around the country. Co-chaired by the health commissioners of Florida and Chicago, the meeting attracted 21 health commissioners or their deputies from 18 cities and states, as well as three representatives from the Centers for Disease Control. The purpose of the meeting was to impress upon health officials just how harmful high-sodium diets are and to explain how these individuals could play a role in their jurisdictions, and across the United States, to reduce sodium levels in the food supply. The agenda included a discussion of sodium-reduction initiatives in the United Kingdom and Finland; a brainstorming session on possible actions and strategies; and a panel discussion about the lessons learned from the trans-fat and menu-labeling initiatives that CSPI has coordinated under the campaign and which have led to the mandatory labeling of trans fat on Nutrition Facts labels and to chain restaurants listing detailed nutrition information on menus and menu boards in several cities and states nationwide. Based on the meeting, 10 health departments filed comments with the U.S. Food and Drug Administration

(FDA) urging the agency to revoke the “Generally Recognized As Safe" or GRAS, status of sand have reclassifiedas a (more tightly regulated“food

additive.” This support from health officials helps bolster CSPI’s advocacy on salt, which began 30 years ago with a petition to revoke salt’s GRAS status and require better labeling of sodium.

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Tcollaborate with one another in pressing the food industreduce sodium levels. And in October 2008, health officials from around the country held a confidential meeting with about 15 food manufacturers to challenge them to voluntarlower sodium levels. Around this time, CSPI also organized a teleconference of health officials during which a New York City official explained how his city is using its procurement policies to preindustry to reduce sodium levels. These “wins” arepart of a larger list of aby CSPI and the CSPI-CECHE CamHealthy Hearts to influence government policy and improve corporate practices. Other successes over the years haveincluded getting nutrition information on nearly all packaged foods and requiring that common allergens be listed clearon food labels. CSPI has also helped to slash the amount trans fat in the American diet through petitions demanding their mandatory listing on Nutrition Facts labels and requiring restaurants to disclose the use of shortenings that contain them; the launch of an interactive Web site, www.transfreeamerica.com; strategically publicized studand efforts; and constant industry and congressional pressurefor voluntary and regulatory actions to reduce trans-fat use and consumption.

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medical experts waging a global campaign against salt. It also partners with national professional associations, including the American Medical Association, which pasa resolution emphasizing the need to achieve 50 percent sodium reductions for processed and restaurant foods, anurging the FDA to revoke salt’s GRAS status.

In July 2007, CSPI and several prominent health care organizations co-signed a letter to the chairman of the Energy and Commerce Health Subcommittee urging him to hold a hearing on salt reduction in the American diet. A long-overdue hearing on the subject was held by the FDA in November 2007.

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The Center For Communications, Health & The Environment (CECHE)

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